Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) during wound care for a resident with a chronic right gluteal pressure ulcer. On the observed date, an LVN and a CNA entered the resident's room, which had an EBP sign posted, but neither performed hand hygiene nor donned the required personal protective equipment (PPE) such as gowns and gloves before making physical contact with the resident. Both staff members proceeded to turn the resident and provide care without following these infection control protocols. The resident involved was an elderly male with a history of a chronic right gluteal pressure ulcer, iron deficiency, and anemia, and was severely cognitively impaired. His care plan required the use of pressure-reducing devices, regular wound care, and the application of nonsurgical dressings and medications. During the observed care, a second stage II ulcer was identified, and it was noted that the wound dressing was missing, which had not been reported to the licensed staff as required by facility protocol. Interviews with the involved staff revealed that both had been trained on EBP and the necessity of using PPE when caring for residents with wounds, but they could not provide a reason for not following these procedures during the incident. The DON confirmed that EBP signage was in place and that staff were expected to use gowns and gloves for direct contact with residents under these precautions. The facility's infection control policy required hand hygiene and the use of PPE to prevent the spread of infection, but these protocols were not followed during the observed care.